Implementing Physiotherapy Huntington's Disease Guidelines in Clinical Practice.

BACKGROUND: The recently published clinical practice guideline for physiotherapy practice for Huntington's disease (HD) should be integrated into practice to develop interventions that enable people with HD to achieve personalised goals. The European Huntington's Disease Network Physiotherapy Working Group aims to support and enable the use of best evidence in physiotherapy for the HD community. Successful implementation of the clinical practice guidelines requires an understanding of facilitators and barriers to therapist implementation. OBJECTIVE: To explore facilitators and barriers to implementing recently published clinical recommendations that guide physiotherapy practice for HD. METHODS: An online survey was distributed globally through HD networks. Data collected included demographic information and agreement/disagreement with a series of named facilitators and barriers to implementation of each of the six physiotherapy guideline recommendations. A consensus level of≥70% agreement was set as indicative of agreement/disagreement. RESULTS: Thirty-two physiotherapists working in a range of settings responded. Support from colleagues (81-91% agreement), an individualised physiotherapy plan (72-88% agreement) and physiotherapist's expertise in HD (81-91% agreement) were reported as facilitators. The main barriers were behavioural (72-81% agreement) and cognitive (75-81% agreement) impairments and low motivation (72-78% agreement) in persons with HD. CONCLUSION: Physiotherapists agree that their expertise in HD and support from colleagues facilitate the development of individualised treatment plans. Further work needs to develop creative ways in which barriers specific to the cognitive and behavioural aspects of HD can be managed to enable treatment plans to be implemented.

Backward Walking and Dual-Task Assessment Improve Identification of Gait Impairments and Fall Risk in Individuals with MS.

BACKGROUND: Individuals with multiple sclerosis (MS) experience deficits in motor and cognitive domains, resulting in impairment in dual-task walking ability. The goal of this study was to compare performance of forward walking and backward walking in single- and dual-task conditions in persons with MS to age- and sex-matched healthy controls. We also examined relationships between forward and backward walking to cognitive function, balance, and retrospective fall reports. METHODS: All measures were collected in a single session. A 2 × 2 × 2 mixed model ANOVA was used to compare differences in forward and backward walking in single- and dual-task conditions between MS and healthy controls. Spearman correlations were used to examine relationships between gait and cognitive function, falls, and balance. RESULTS: Eighteen individuals with relapsing-remitting MS and 14 age- and sex-matched healthy controls participated. Backward walking velocity revealed significant differences between groups for both single-task (p = 0.015) and dual-task (p = 0.014) conditions. Persons with MS demonstrated significant differences between single- and dual-task forward and backward walking velocities (p = 0.023; p = 0.004), whereas this difference was only apparent in the backward walking condition for healthy controls (p = 0.004). In persons with MS, there were significant differences in double support time between single- and dual-task conditions in both backward (p < 0.001) and forward (p = 0.001) directions. More falls at six months were significantly associated with shorter backward dual-task stride length (r = -0.490; p = 0.046) and slower velocity (r = -0.483; p = 0.050). CONCLUSION: Differences in MS and age- and sex-matched healthy controls are more pronounced during backward compared to forward walking under single- and dual-task conditions. Future work with a larger sample size is needed to validate the clinical utility of backward walking and dual-task assessments and mitigate the limited sensitivity of the current dual-task assessments that primarily rely upon forward walking.

Supplementary motor area connectivity and dual-task walking variability in multiple sclerosis.

BACKGROUND: Despite the prevalence of dual-task (e.g., walking while talking) deficits in people with multiple sclerosis (MS), no neuroimaging studies to date have examined neuronal networks used for dual-task processing or specific brain areas related to dual-task performance in this population. A better understanding of the relationship among underlying brain areas and dual-task performance may improve targeted rehabilitation programs. The objective of this study was to examine relationships between neuroimaging measures and clinical measures of dual-task performance, and reported falls in persons with MS. MATERIALS AND METHODS: All participants completed measures of dual-task performance, a fall history, and neuroimaging on a 3 T MRI scanner. Spearman correlations were used to examine relationships among dual-task performance, falls and neuroimaging measures. RESULTS: Eighteen females with relapsing-remitting MS [mean age = 45.5 ±â€¯8.2 SD; mean symptom duration = 12.3 ±â€¯6.7 years; Expanded Disability Status Scale median 2.25 (range 1.5-4)] participated in this study. Structural imaging measures of supplementary motor area (SMA) interhemispheric connectivity were significantly related to dual-task walking variability. CONCLUSIONS: The SMA interhemispheric tract may play a role in dual-task performance. Structural neuroimaging may be a useful adjunct to clinical measures to predict performance and provide information about recovery patterns in MS. Functional recovery can be challenging to objectively report in MS; diffusion tensor imaging could show microstructural improvements and suggest improved connectivity.

Are triage questions sufficient to assign fall risk precautions in the ED?

OBJECTIVES: The American College of Emergency Physicians Geriatric Emergency Department (ED) Guidelines and the Center for Disease Control recommend that older adults be assessed for risk of falls. The standard ED assessment is a verbal query of fall risk factors, which may be inadequate. We hypothesized that the addition of a functional balance test endorsed by the Center for Disease Control Stop Elderly Accidents, Deaths, and Injuries Falls Prevention Guidelines, the 4-Stage Balance Test (4SBT), would improve the detection of patients at risk for falls. METHODS: Prospective pilot study of a convenience sample of ambulatory adults 65 years and older in the ED. All participants received the standard nursing triage fall risk assessment. After patients were stabilized in their ED room, the 4SBT was administered. RESULTS: The 58 participants had an average age of 74.1 years (range, 65-94), 40.0% were women, and 98% were community dwelling. Five (8.6%) presented to the ED for a fall-related chief complaint. The nursing triage screen identified 39.7% (n=23) as at risk for falls, whereas the 4SBT identified 43% (n=25). Combining triage questions with the 4SBT identified 60.3% (n=35) as at high risk for falls, as compared with 39.7% (n=23) with triage questions alone (P<.01). Ten (17%) of the patients at high risk by 4SBT and missed by triage questions were inpatients unaware that they were at risk for falls (new diagnoses). CONCLUSIONS: Incorporating a quick functional test of balance into the ED assessment for fall risk is feasible and significantly increases the detection of older adults at risk for falls.

Motor performance differentiates individuals with Lewy body dementia, Parkinson's and Alzheimer's disease.

INTRODUCTION: Differential diagnosis of dementia with Lewy bodies (DLB), Parkinson's disease with dementia (PDD), Parkinson's disease (PD) and Alzheimer's disease (AD) is challenging. Comparative motor profiles of these neurodegenerative disorders may aid in earlier diagnosis but have not been extensively studied. METHODS: Groups were rigorously matched by age, education, and sex. DLB/PDD participants were matched by Mini-Mental State Examination Score to individuals with AD and by Unified Parkinson's Disease Rating Scale motor scores to individuals with PD. Gait, balance, dual task walking and hand dexterity measures were compared between a combined group (n=21) of individuals with Lewy body dementia (LBD) consisting of those with DLB (n=11) and PDD (n=10) to individuals with PD (n=21) or AD (n=21). RESULTS: Individuals at the same disease stage with LBD walked significantly slower with shorter stride lengths (p<0.05), demonstrated poorer balance on both the Tinetti and Berg Balance Scale, and poorer performance on dual-task and figure-of-eight walking compared to PD and AD (p<0.05 for all) groups. Upper extremity coordination on the 9-hole peg test differentiated LBD from both PD and AD and was the only motor test in which individuals with AD performed worse than those with PD. Tinetti balance subscores were significantly lower in PDD compared to DLB participants (10.4±2.3 versus 12.8±2.3; p=0.027). CONCLUSIONS: Motor features distinguish individuals with LBD from those with AD and PD. Measures of gait, balance and finger dexterity provide an additional means of differentiating individuals with LBD from those with AD and PD.

Reliability and validity of a wireless accelerometer for the assessment of postural sway.

Clinicians are in need of valid and objective measures of postural sway. Accelerometers have been shown to be suitable alternatives to expensive and stationary force plates. We evaluated the test-retest reliability and balance task discrimination capability of a new wireless triaxial accelerometer (YEI 3-Space Sensor). Four testing conditions (eyes open or closed, while on a firm or compliant surface) were used to progressively challenge the static balance of 20 healthy male (n = 8) and female (n = 12) older adults (mean age 81 ± 4.3 y). Subjects completed 2 blocks of three 30-second trials per condition. The accelerometer was positioned on the lower back to acquire mediolateral (M-L) and anterior-posterior (A-P) accelerations. Intraclass correlation coefficients were all good to excellent, with values ranging from .736 to .972 for trial-to-trial and from .760 to .954 for block-to- block. A significant stepwise increase in center of mass acceleration root mean square values was found across the 4 balance conditions (F[1.49, 28.26] = 39.54, P < .001). The new accelerometer exhibited good to excellent trial-to-trial and block-to-block reliability and was sensitive to differences in visual and surface conditions and acceleration axes.

Rethinking energy in parkinsonian motor symptoms: a potential role for neural metabolic deficits.

Parkinson's disease (PD) is characterized as a chronic and progressive neurodegenerative disorder that results in a variety of debilitating symptoms, including bradykinesia, resting tremor, rigidity, and postural instability. Research spanning several decades has emphasized basal ganglia dysfunction, predominantly resulting from dopaminergic (DA) cell loss, as the primarily cause of the aforementioned parkinsonian features. But, why those particular features manifest themselves remains an enigma. The goal of this paper is to develop a theoretical framework that parkinsonian motor features are behavioral consequence of a long-term adaptation to their inability (inflexibility or lack of capacity) to meet energetic demands, due to neural metabolic deficits arising from mitochondrial dysfunction associated with PD. Here, we discuss neurophysiological changes that are generally associated with PD, such as selective degeneration of DA neurons in the substantia nigra pars compacta (SNc), in conjunction with metabolic and mitochondrial dysfunction. We then characterize the cardinal motor symptoms of PD, bradykinesia, resting tremor, rigidity and gait disturbance, reviewing literature to demonstrate how these motor patterns are actually energy efficient from a metabolic perspective. We will also develop three testable hypotheses: (1) neural metabolic deficits precede the increased rate of neurodegeneration and onset of behavioral symptoms in PD; (2) motor behavior of persons with PD are more sensitive to changes in metabolic/bioenergetic state; and (3) improvement of metabolic function could lead to better motor performance in persons with PD. These hypotheses are designed to introduce a novel viewpoint that can elucidate the connections between metabolic, neural and motor function in PD.

Rehabilitation and functional outcomes after extensive surgical debridement of a knee infected by fusobacterium necrophorum: a case report.

BACKGROUND AND PURPOSE: Joint infection is a rare but serious complication after knee injury that should be part of a physical therapist's differential diagnosis. This case report presents the care of a 17 year-old female athlete with septic arthritis from a Fusobacterium infection after sustaining a right lateral meniscus tear. Joint pathology combined with the aggressive infectious agent led to arthrofibrosis of her knee joint and resultant activity limitations and participation restrictions. The purpose of this case report is to highlight a rare and unique pathology, the serious effects that a joint infection can have on musculoskeletal function, and the challenges encountered during the rehabilitation process. CASE DESCRIPTION: The subject was a 17 year-old volleyball player who injured her right knee while playing volleyball. Within 7 days, the subject developed a severe joint infection that spread into surrounding gluteal, quadriceps, and gastrocnemius musculature. The infection was surgically debrided eight times during a 10-week inpatient hospital stay. A manipulation under anesthesia was performed to restore range of motion in her knee joint. Outpatient physical therapy was initiated 4 days later in order to restore musculoskeletal function. OUTCOME: Over eight months of physical therapy services were utilized to address the impairments and activity limitations caused by her joint dysfunction. She met her physical therapy goals and made significant improvements on the Knee Outcome Survey and the Lower Extremity Functional Scale. Success in physical therapy and completion of additional strength training exercise allowed this subject to return to competitive softball at the club level during her freshman year of college. DISCUSSION: Though rare after musculoskeletal injury, joint infection can lead to soft tissue damage, partial or complete degradation of articular cartilage, and arthrofibrosis causing significant disability. Physical therapists must incorporate evidence-based treatment principles including eccentric exercise, core stability, and lower extremity strength training along with sports-specific rehabilitation into the treatment plan in order to address activity limitations and meet physical therapy goals. LEVEL OF EVIDENCE: Level 4-Single Case report.

The impact of different types of assistive devices on gait measures and safety in Huntington's disease.

BACKGROUND: Gait and balance impairments lead to frequent falls and injuries in individuals with Huntington's disease (HD). Assistive devices (ADs) such as canes and walkers are often prescribed to prevent falls, but their efficacy is unknown. We systematically examined the effects of different types of ADs on quantitative gait measures during walking in a straight path and around obstacles. METHODS: Spatial and temporal gait parameters were measured in 21 subjects with HD as they walked across a GAITRite walkway under 7 conditions (i.e., using no AD and 6 commonly prescribed ADs: a cane, a weighted cane, a standard walker, and a 2, 3 or 4 wheeled walker). Subjects also were timed and observed for number of stumbles and falls while walking around two obstacles in a figure-of-eight pattern. RESULTS: Gait measure variability (i.e., coefficient of variation), an indicator of fall risk, was consistently better when using the 4WW compared to other ADs. Subjects also walked the fastest and had the fewest number of stumbles and falls when using the 4WW in the figure-of-eight course. Subjects walked significantly slower using ADs compared to no AD both across the GAITRite and in the figure-of-eight. Measures reflecting gait stability and safety improved with the 4WW but were made worse by some other ADs.

Interdisciplinary allied health education in treating older adults with low vision.

In 2000, the number of elderly citizens in the United States was 35 million, an increase of 3.7 million (11%) since 1990. Of these older adults, approximately 1.3 million (4%) have a low vision impairment. Older adults make up two-thirds of those diagnosed with a visual impairment. Low vision impairment, which is different from the typical vision changes associated with aging, occurs because of a chronic visual disorder that cannot be corrected medically, surgically, or with conventional eyeglasses, most often resulting in disability. The leading causes of low vision impairment are diabetic retinopathy, cataract, glaucoma, and age-related macular degeneration. Combined with the other physical changes associated with aging, the development of a low vision impairment further challenges the functional performance and safety of those 65 and older. Furthermore, the psychological impact from the physical changes accompanying aging is compounded for those with a low vision impairment. In response to the health needs of all age groups, Healthy People 2010 has established overarching goals to increase quality and years of healthy life and eliminate health disparities. An interdisciplinary course for allied health students was developed to support future health care providers in improving quality of life for older adults with low vision and help decrease health disparities in this population. This paper reports on the pilot experience with this course.